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Jan 16, 2023, 06:35 ET

HUNTINGTON BEACH, Calif., Jan. 16, 2023 /PRNewswire/ — Coast Surgery Center is an outpatient surgery center in the city of Huntington Beach, CA and has been in business since 2018. Coast is a facility for outpatient procedures offering healthcare related services. Just like most medical facilities, before services are rendered to a patient, the provider and facility obtain authorization with the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) rate for the procedure. Based on the UCR rate provided by the insurance, the provider and patient understand that if they are to proceed, how much the insurance company will reimburse. All the information obtained is documented by both the insurance carrier and facility as a part of their policy and practice.

Coast provides services to its patients relying on the insurance representations solely based on their statements, promises, and representations. By authorizing a procedure, insurance companies are granting Coast to provide healthcare services to their members, and Coast is fulfilling the insurances’ contractual obligations to its members.

The insurance companies significantly started reducing the reimbursement rate from UCR to below Medicare rate in 2018, and for some claims, they didn’t pay at all. Since 2019, Coast Surgery Center accumulated bills totaling over $6M. So now Coast is suing some of the largest health insurance providers in the country; United Health Care, Cigna, Aetna, Anthem Blue Cross of California, Blue Shield of California, Blue Cross Blue Shield Associates, and all Blue Cross Blue Shield affiliated companies for illegal, coercive, unfair, fraudulent practices, bad faith and deceptive advertisements.

In the civil case #30-2022-01271476-CU-CO-CJC filed by Coast Surgery Center in Orange County, California, Coast states they billed Blue Cross $49,550 for a surgery and Blue Cross paid $202.99. This is an example for many of the underpaid bills. Insurance companies have had a history of lawsuits for underpaying. As of June 30, 2019, 43% of Anthem’s medical bills were unpaid. By 2021, that figure rose to 53%, resulting in a total of $2.5 billion unpaid bills. Yet, Anthem’s profits in 2020 were reported to be $4.6 billion and $3.5 billion in the first half of 2021.

These unpaid bills harm medical providers like Coast by failing to provide reasonable rates for its services, negatively impacting the quality of service, value of Coast, and significantly impacting Coast’s business relationship with patients and prospects. With this lawsuit, Coast is hoping that the big insurance companies will stop taking advantage of small providers as Coast will continue to provide critical, quality healthcare services and treatment to its Defendants’ members on its behalf and hope to be paid reasonable rates.

Coast Surgery Center of Huntington Beach, CA is suing some of the largest health insurance providers in the country; United Health Care, Cigna, Aetna, Anthem Blue Cross of California, Blue Shield of California, Blue Cross Blue Shield Associates, and all Blue Cross Blue Shield affiliated companies for illegal, coercive, unfair, fraudulent practices, bad faith and deceptive advertisements.

When patients need a provider, they often look for an in-network provider to save them money but when a patient requires an out-of-network specialist or wants a provider they trust, insurance carriers like Blue Cross, utilize a separate rate for these out-of-network providers. Even before services are rendered to a patient, the out-of-network provider and facility obtain authorization with the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) rate. Based on the UCR rate provided by the insurance, the provider and patient understand that if they are to proceed, how much the insurance company will reimburse.

This lawsuit arises because Blue Cross is intentionally underpaying Coast Surgery Center even after Coast had obtained authorization and was provided with the UCR rates from Blue Cross.  Blue Cross’s scheme was to significantly reduce the reimbursement rate from UCR to below Medicare rate and this is a “take it or leave it” offer.

For example, Coast Surgery Center billed Blue Cross $49,550 for a surgery and Blue Cross paid $202.99! Medical facilities cannot stay in business and offer quality service to patients when they are unable to cover rent, let alone utilities, supplies, and staff. Why would a patient purchase insurance coverage that’s hundreds of dollars a month when they can walk into a surgery center and just pay only $202.99 for their surgery? It’s inconceivable that Blue Cross can consider this “usual, customary, and reasonable.” Blue Cross was paying 75% – 100% of approved out-of-network charges to Coast Surgery Center prior to 2019 but since 2019 to July 2022, Blue Cross has only paid 1.59% of bills totaling over $6M, for the same procedures they have approved before, so how is this “usual, customary, and reasonable?”

Blue Cross collects billions of dollars from insurance premiums each year but is too greedy to pay out the providers that have rendered services to patients. Blue Cross is the middle man taking money from customers, paying pennies to the dollar to providers, and keeping a large chunk for themselves without having to lift a finger. Contrary to their claims that they care about reducing member healthcare costs, patients have been forced to pay more for their healthcare as a result of their scheming practices, while giving less access to providers of choice. If Blue Cross is not stopped, they will ruin out-of-network medical providers, patients will have limited choices, and the quality of care will diminish. Blue Cross is manipulating the system and have conspired with third-party servicers like Multi-plan to defraud many out-of-network providers by coercing them into servicing patients with authorization and then extorting the providers into contracts that only offer significantly reduced rates leaving them in an impossible position.

When deciding their health and the well-being of their families, patients want to be able to select their doctor based on their needs, not based on the insurance carrier’s pool of what they have to offer. Blue Cross forces patients to pay higher out-of-pocket costs for using out-of-network providers, ultimately, its practices increase costs and deprive patients of their right to choose their doctors.

Blue Cross and many large insurance companies pay lobbyists to help create laws that allow them loopholes to be able to get away with cheating their customers. Customers then purchase insurance policies that might not even cover them when they need it. When customers get frustrated and demand the insurance to pay or want to ring the alarm, the insurance company pays Medicare rate, instead of paying the UCR rates as they really should be. This doesn’t make any sense when insurance premiums increase annually, and coverage keeps decreasing.

California tax payers including patients, doctors, and facilities fund the Department of Insurance and the Department of Managed Healthcare (DMHC) so that they can ensure consumers of their healthcare rights and to protect consumers from being cheated. Yet these departments have ignored these insurance companies or are not aware of their tactics. These Departments should be protecting consumers and investigating these insurance payout processes because the insurance companies are working the system and using the loophole to scam customers of millions of dollars in premiums and paying out next to nothing or nothing at all. So the Dept of Insurance and DMHC should be protecting patients, instead of protecting the health insurance companies and letting them work the system.

If you are a medical provider or facility that feels you’ve been pressured by insurance companies to accept an unreasonable rate for your services, file your complaint with the Department of Managed Health Care by calling (888) 466-2219 https://www.dmhc.ca.gov/ or write to them at 980 9th St., #500, Sacramento, CA 95814. You can also contact the Department of Insurance at (800) 927-4357 https://www.insurance.ca.gov/ or your local political representative – who are no paid directly or indirectly by lobbyists for those private health insurance companies. You can also share your story with Truth Media or be referred for legal representation with a specialized attorney for your case against the insurance companies for illegal, coercive, unfair, fraudulent practices, bad faith, and deceptive advertisements by emailing info@truthmedia.news.

Published on Apr 08, 2022 – The Capitol Forum

Multiplan (MPLN) says that it provides “independent, fair, and reasonable” pricing for out-of-network healthcare services.

Previous Capitol Forum reporting showed that Multiplan’s pricing is not independent, as it can be manipulated by insurers.

According to Capitol Forum’s ongoing investigation, Multiplan’s pricing is also not “fair and reasonable,” as the pricing appears to be based on maximizing profits, and, in one case, Multiplan admitted that, when setting prices, it relied on how much Multiplan discounted from the provider’s previous billed charges. Basing pricing on the percentage discounted from a provider’s previous charges is not a process that could reasonably be described as yielding “independent, fair, and reasonable” pricing for healthcare services, but it is perfectly logical for Multiplan since the company is paid based on the percentage difference between billed rates and prices paid by insurers.

Multiplan argues that its services that bring in “shared savings” fees help employers and patients, but when Multiplan cuts the rates for healthcare claims, either the employer is hurt by an increase in fees or the patient is hurt by receiving a large “balance bill.”

For this article, we focus primarily on three medical billers’ interactions with Multiplan.

One biller showed how Multiplan punished him for lowering his billing rate and rewarded him for raising his billing rate.

Another biller showed how Multiplan pricing left patients with big increases in out-of-pocket costs for physical therapy services.

Another biller described the process of Multiplan’s pricing as difficult to manage, opaque, and dramatically lower than pricing done by non-Multiplan-affiliated plans.

Each of the billers emphasized the amount of administrative time and expense that was necessary to deal with Multiplan-facilitated claims and to educate patients about unexpected increases in their portion of the bill.

For this part of its investigation, The Capitol Forum reviewed redacted “fee negotiation” communications between Multiplan and providers, insurance claim payment remittances, and documents filed in several lawsuits, including depositions, trial transcripts, and exhibits; interviewed several providers and owners of medical billing companies who spoke under the condition of anonymity because of concerns about retaliation from Multiplan and payors; read online provider complaints posted by providers; and interviewed a former Multiplan fee negotiator.

Multiplan spokesperson’s comments. “All of our pricing methodologies are fair, transparent and reasonable. Multiplan absolutely does not encourage providers to overcharge for their services—that is completely in opposition to our mission and would not be tolerated by us or by our clients,” a Multiplan spokesperson told The Capitol Forum in an emailed statement.

The Multiplan Billing Experience vs. the Typical Health Plan Billing Experience

Whereas a typical health plan sets an allowable rate for a healthcare service, some health plans first route out-of-network claims to Multiplan’s “negotiating services.” In effect, a provider sends a bill to the insurance plan, the plan routes the claim to Multiplan who offers an “adjusted price” (or “negotiated rate”) as part of a negotiation. Providers told The Capitol Forum that the adjusted price offer is a take-it-or-leave-it proposal. If the provider accepts the adjusted price, then the provider agrees not to balance bill.

This creates an unusual circumstance when there is a large gap between the billed charge and agreed negotiated rate. When setting future adjusted prices for a provider’s claims, Multiplan appears to rely on the percentage discounted from the billed charge rather than a specific dollar amount for a given service. When a provider decides to bill a subsequent claim for the same service at Multiplan’s previously accepted adjusted price, Multiplan responds with an almost proportionately lower adjusted price offer.

Effectively, negotiated rates with Multiplan, after the first negotiation, are phantom rates because Multiplan appears to stabilize the percentage gap between what a provider bills and the adjusted price the provider accepts. The provider knows what adjusted price Multiplan offered previously, but the provider will not be offered the same adjusted price again unless the billed charges remain at an inflated amount.

If the provider rejects Multiplan’s negotiated rate, the claim is paid much lower than the typical allowable rate which results in the provider balance billing the patient for the difference between the billed price and the allowable rate.

Here are some examples of out-of-network claims sent to health insurance plans that use Multiplan pricing services and the end results of those negotiations with Multiplan.

Employers who self-fund health plans for employee health coverage pay insurance companies to administer the plan. The insurance companies charge employers fees, including fees for out-of-network claim management services and, when Multiplan is involved, the insurance company shares a portion of that fee revenue with Multiplan.

If the provider accepts Multiplan’s negotiated payments, then the employer pays high “shared savings” fees to the insurance company administering the health plan. Shared savings fees are based on a percentage of the amount between providers’ billed charges and the negotiated amount shown on the claim statement. Previously, The Capitol Forum reported on employers’ dissatisfaction with the shared savings fees.

Case Study 1: Biller for Surgery Centers

A biller who works in a western state with surgeons and surgery centers for specialties including neurosurgery, bariatrics, and gynecology, told The Capitol Forum in an interview, “The typical allowable rate received by our facility for complex upper endoscopy procedures performed prior to bariatric surgery was between $6,000 and $8,000. However, Multiplan and Anthem (ANTH) refused to honor that price unless we billed three to four times higher” than the negotiated rate.” So, the biller said he typical billed between $18,000 to $28,000—and sometimes as high as $32,000—to get paid between $6,000 to $8,000 from the Multiplan-affiliated health plans.

Then, in May 2020, the biller said Multiplan suddenly reduced its negotiated price to $3,539. The biller billed $32,000 to get the $3,539 adjusted price from Multiplan. He agreed to accept that rate as full payment and promised not to balance bill, as is required when providers accept a negotiated rate offered by Multiplan.

In June 2021, the biller dropped his price to $24,000, and Multiplan dropped its negotiated rate to $3,096, which the biller accepted.

Finally, in November 2021, the biller dropped his billed rate to $4,500 because he no longer wanted to choose between writing off larger amounts and balance billing patients. The biller anticipated that Multiplan’s negotiated rate of $3,096 or $3,539 would leave a more manageable $1,000 or $1,500 to write off or to balance bill to the patient.

But, instead of offering close to the previous adjusted prices of $3,096 or $3,539, Multiplan responded to the provider’s price cut by slashing the negotiated rate down to $673.65.

Source: Redacted Multiplan negotiated offer

In voicemails left by a Multiplan negotiator, the biller said he was told, “the claim is set at the same rate, as far as percentage goes. I am not able to increase it due to the maximum allowed amount.” According to the biller, the Multiplan negotiator in a follow up call “confirmed that the previous rate of $3,500 will not be offered until I increase the billed total.”

The biller persisted in asking questions about the formula Multiplan used to justify a decrease in the offered rate from $3,500 to $673.65 for the same procedure. He said the negotiator explained, “The allowable amount percentage is based on the percentage you had accepted in previous Anthem claims for similar plan and similar procedures.”

In reality, the new Multiplan payment was roughly 15% of the billed amount, whereas the previous offers were roughly 13% and 11% of billed charges, so it is unclear what the Multiplan representative meant by saying “the rate was the same, as a percentage.” But the explanation does indicate that, rather than independently assessing a “fair” price, Multiplan adjusts negotiated rates to maintain the percentage gap between billed charges and the offered price.

In a subsequent claim, the biller raised the charge to $28,000, and Multiplan increased the amount it offered to $2,548, thereby rewarding him for raising the price more than sixfold.

Anthem did not respond to a request for comment.

Physical Therapy

A medical biller for several physical therapists in the northeast told The Capitol Forum that they bill around $400 for an hour long out-of-network follow-up visit which, the biller said, is a rate many insurers accept. That means that a patient covered by a health plan with out-of-network benefits can meet a $1,200 deductible in three visits because, for each visit, the plan credits a $400 allowable rate towards the deductible. After the deductible is met, for a plan that has a 60/40 split between the health plan and patient, the plan will pay $240 of the bill leaving the patient to pay the remaining $160. So, a patient covered by a plan that has a $400 allowable would pay $2,320 for 10 follow-up physical therapy visits.

But for claims processed by Multiplan, the allowable rate is set at $151. The patient is still obligated to pay the provider $400 every visit but, since only $151 applies towards the deductible, it would take eight visits to meet a $1200 deductible. After the deductible is met, for a Multiplan-affiliated plan that is a 60/40 split between plan and patient, the plan only pays $91 for each visit, leaving patients to pay the remaining $309. So, 10 follow-up physical therapy visits would cost a patient covered by a plan that uses Multiplan close to $3,800.

That type of jump in out-of-pocket costs for patients can damage the relationship between the patient and healthcare provider and can cause patients to grow frustrated with their employer who provides the insurance.

The medical biller explained that she started seeing the drop in allowable for certain plans at the beginning of 2021. The allowable rate was reduced by Data iSight, Multiplan’s repricing service, and that she has not seen any negotiated offers. She said she has been making a lot of calls to Multiplan and Data iSight and Viant, which are companies under Multiplan’s umbrella, to ask questions and to help her patients get the benefit of the higher premiums they are paying for health plans with out-of-network benefits.

It is a challenge, she said, because the Multiplan representatives only allow her to ask five questions per call whether they can answer the questions or not.

Addiction Treatment Centers

An executive at a company that manages billing for addiction treatment centers located in multiple states told The Capitol Forum, “Multiplan is not the worst offender, Viant is much worse!” Although her company has dealt with Multiplan and Viant for years, she was unaware that Viant is a Multiplan company. Several sources who spoke to The Capitol Forum were under the impression that Viant, Medical Audit and Review (MARS), Data iSight, and Multiplan were unrelated companies.

The addiction treatment center biller said she “feels defenseless against [Multiplan and Viant].” She added that her peers in the addiction treatment industry feel the same way.

An example provided by the biller shows a negotiated offer from Viant on a claim for two days of intensive outpatient group therapy at three hours a day. The patient’s plan, which is managed by United Healthcare “states it pays 80% of usual and customary rates,” she said. “I averaged the out-of-network amount we see for the same service from UnitedHealth plans that have the same usual and customary rate language and don’t use Viant. The average comes to $924.”

The claim was billed at $3,700. Viant offered $323.58, according to the redacted negotiated offer reviewed by The Capitol Forum.

Some insurers actually publish their allowable rates, she said. “We have asked on multiple occasions how [Multiplan and Viant] determine what gets sent out for pricing,” she said. “They will not divulge what their methodology is. Typically, we get a representative who says they have no control over what gets sent out for Multiplan pricing.”

“When we reject a negotiation, it takes months to get any payment and we never get paid more than the amount on the negotiation offer. Anytime we say no, we are stuck waiting for payment.” She added that sometimes she noticed “for the same patient and the same provider, one claim will be priced by Multiplan and a different claim is priced by the payor. We’ve called on these before and were informed that the higher priced claim was incorrect, and a recoupment will follow.”

The addiction treatment industry overall has actually been dealing with concerns about Multiplan for years. In a 2016 article in Sober World, an owner of California addiction treatment centers wrote, “As the major insurance companies don’t like paying for effective addiction treatment, they are using companies owned by Multiplan to reprice California’s small, non-medical treatment facilities using irrelevant data from Medicare.”

In recent years, addiction treatment providers have filed numerous lawsuits against Multiplan and insurers for underpaying claims. The cases are in active litigation.

Article Source Link: https://thecapitolforum.com/provider-shows-how-multiplan-incentivizes-him-to-raise-his-billing-rate-multiplan-says-it-does-not-encourage-providers-to-overcharge/?fbclid=IwAR2wrLESHjJzNxacvmRs8DVFUa6V5yh43mXeQM2ZxzHhHxantTNJXpPXzr4